HD001

5 Axes of Diagnosis

 Erikson’s 3 Concepts

Axis I

Clinical disorders

Axis II

 Personality Disorders, Mental Retardation

Axis III

General medical conditions

Axis IV 

Psychosocial and environmental problems (Ex. marital breakup, poverty...)

Axis V 

Global Assessment of Functioning

1. Psychosocial Crisis - a turning point in   psychology -> developmental crossroad. Can go well or poorly
2. Fixation - persistent attachment to the entire complex of self and object relation
3. Regression – preoccupation with a previous stage

HD002

Erikson’s Stages of Development (generally)

Infancy - Basic Trust vs. Mistrust
Birth to about 2 years. Foundation for a secure attachment. If not met, it can lead to lifelong mistrust

Toddler - Autonomy vs. Shame & Doubt

Age 2 to 3
Success = self-control, and pride

Preschool - Initiative vs. Guilt (aka Early Childhood)

Ages 3 to 6. Stage of play and make-believe.
Success: spontaneity, assertiveness, conscience.

Elementary - Industry vs.Inferiority (Early School-Years)

Ages 6 to 11. Shift from play to work & evaluation.
Success: mastery of skills, goal-oriented, and productive
Start to see the early signs of developmental disability

Adolescence - Identity vs. Role Confusion

Teenage years
Success: exploring options and making commitments (values, career path, goals)

Young adult - Intimacy vs. Isolation

“twenties”
Success: establishing mature relationships

Adulthood - Generativity vs. Stagnation

Age 30 to 65
Recognition of mortality, concern for legacy, altruism.
Mid-life crisis.

Old Age - Ego Integrity vs. Despair (Late Adulthood)

Age 65+
Was life meaningful?
Ready to accept death, or filled with regrets?

HD004

Live birth

Total births

Gestational age

Low birth weight

Delivery

Gravida

Para

Abortion

Stillbirth

Live Birth: The complete expulsion or extraction from its mother irrespective of the duration of pregnancy, of a product of conception in which, after such expulsion or extraction, there is breathing, beating of the umbilical cord, or unmistakable movement of voluntary muscle, whether or not the umbilical cord has been cut or the placenta attached.

Total births: All live births and still births

Gestational age: The duration of gestation measured from the first day of the last normal menstrual period. Gestational age is expressed in completed days or completed weeks.

Pre-term: less than 37 weeks gestation (<259)
Term: between 37-41 weeks gestation (259 - 286)
Post-term: > 41 weeks of gestation (>286)

Low birth weight: Deliveries (live or stillborn) weighing less than 2500 grams at birth

Delivery: Refers to the completion of a pregnancy, regardless of how many fetuses involved

Gravida: the number of times a woman has conceived.

Para: the number of times a woman has given birth regardless of the number of fetuses involved

Abortion: The complete expulsion or extraction from its mother of a fetus or embryo of less than 20 weeks gestation, whether there is evidence of life or not, and whether the abortion was spontaneous or induced. This usually correlates with a weight of less than 500 grams.

Stillbirth: The birth of a fetus weighing 500 grams or more and/or having a gestational age of ≥ 20 weeks or more.

HD004

Neonatal death

Perinatal death

Delayed neonatal death

Neonatal death: The death of a live born infant occurring less than 28 full days after birth.

Early: before the 7th full day of life.

Late: between the 8th and 28th full day of life.

Perinatal death: All stillbirths (fetal deaths) and early neonatal deaths.

Delayed neonatal death: Death of an infant occurring after 28 days, who without the benefit of an NICU would have died earlier. Perinatal mortality

HD004

Maternal death

The death of a woman known to be pregnant or within 42 days of delivery or termination of the pregnancy, irrespective of the duration of or site of the pregnancy

Direct obstetric: resulting from complications of pregnancy, childbirth, or the puerperium (e.g. exsanguination from rupture of the uterus)

Indirect obstetric: a non-obstetric medical or surgical condition which either antedated pregnancy or was aggravated by the physiologic adaptations to pregnancy (e.g. Mitral stenosis)

Non-obstetric: resulting from accidental or incidental causes in no way related to pregnancy (e.g. automobile accident)

HD004

Strengths and Weaknesses in Manitoba
Pregnancies

Strengths:

• Lower rate of C/S than other areas of Canada
• Less likely to have assisted vaginal birth
• Less likely to have their labor induced
• Birth rate 1.8 per population compared to national rate of ~1.2 %

Weakness:

• Highest teen pregnancy rate of all provinces.
• Rate 3.4x higher in First Nations teens.
• High Stillbirth rate
• Second highest pre-term birth rate
• High rate of low birth weight and high birth weight babies
• Highest rate of neonatal hospital readmissions

HD008

Diagnosis of pregnancy can be done by...(4)

By history
From the first day of the last normal menstrual period, add 7 days then count back three months.

E.g. if LNMP December 18, then Expected Date of Confinement (EDC) would be September 25.

By identification of Beta Human Chorionic Gonadotrophin in urine or blood.
As early as 10-12 days after conception. Home tests will detect levels of 25mIU/L. Tests can be qualitative or quantitative.

+ test can mean:

Healthy intrauterine pregnancy
Abnormal intrauterine pregnancy
Ectopic pregnancy
Gestational trophoblastic disease or choriocarcinoma
Germ cell tumors of the ovary

By Pelvic ultrasound.
As early as 4 weeks. Usually after 1,000mIU is reached. Can count # of fetuses (and rule out ectopic)

By Pelvic  examination can identify uterine enlargement after 6-8 weeks

HD008

Lab tests in ante-partum care

Prenatal Screening Tests (for fetus)

Genetic Counselling for Pregnant Mothers

Hemoglobin and platelet count, Urinalysis, Urine culture, Blood grouping, Rh, Antibody screen, Rubella status, Syphilis screen, Pap smear, HbsAg testing, Hepatitis C screen, STI testing (Chlamydia #1 cause of prenatal blindness), Offer HIV testing

Maternal serum screening offered at 16 -18 weeks

Ultrasound for anatomy screen after 18 weeks

Biophysical profile scoring (via ultrasound):

Fetal breathing, Fetal movements, Amniotic fluid, Fetal breathing movements

• A nuchal chord screen at 12 weeks can predict risk of Down syndrome.
• Maternal serum screening measuring serum estriol, AFP, HCG, it can offer a risk assessment, but for diagnosis need an amniocentesis.
• Offered at the earliest safest point in the pregnancy at 15+ weeks to allow termination if patient so wishes but a risk of foetal loss just from the testing (~1/250)
• A detailed anatomy screen with ultrasound imaging at 18 weeks, with a later reassessment for cardiac abnormalities.

HD008

What does continuing obstetrical care consist of?

Weight Gain and Diet during Pregnancy

Usual frequency of visits every 4 weeks until 28 weeks, then every 2 weeks until 36 weeks, then every week until confinement.

Look at:

• Weight
• BP
• Urinalysis
• Record gestational age
• Measure symphysis-fundal height
• Assess fetal presentation and lie after 28 weeks.
• Listen to fetal heart (after 12 weeks)
• Enquire about fetal movement
• Continuing education and assessment of socio-economic concerns

Weight Gain:

A woman with a normal body mass index should gain between 15-25 pounds during pregnancy.

Low BMI should gain between 28-40 pounds

High BMI should gain between 15-25 pounds

Obese should gain < 15  pounds.

Diet
A daily increase of 300kcal usually adequate

Iron, calcium and folic acid importnant

HD008

Exercise benefits for the pregnant woman

Dental care

Immunizations

• Possibly shorter labors, fewer cesarean sections, less fetal distress in women who are physically fit and continue to exercise
• Recommended that women who are accustomed to exercise continue to do so, but monitor their target heart rates. Women who are sedentary prior to pregnancy will benefit from mild exercise

• Gum swelling is normal, but poor dental hygiene with periodontal disease can increase the risk of pre-term labor

• No live virus or bacterial vaccinations
• varicella, measles, mumps
• Inactivated virus vaccines safe
• influenza
• Immune globulins safe

HD124

Amniotic Fluid:

Input

Loss to Fetus

Function

Input into amniotic fluid comes from

• Oral secretions = 25 ml/d
• Respiratory secretions = 170 ml/d
• Fetal urine (main) = 800-1200 ml/d

Loss to fetus is from

• Swallowing = 500-1000 ml/d
• Loss across placenta = 200-500 ml/d

Function of Amniotic Fluid

• Physical
• Thermoregulation
• Bacteriostasis
• Umbilical cord – compression
• Cushioning external forces
• Developmental
• Decreases loss of lung fluid
• Growth/development of GI
• Development of MS system
• Nutritive

HD124

Amniotic Fluid Volume:

Oligohydramnios

&

Polyhydramnios

Oligohydramnios (too little)
Found if largest pocket of fluid is < 3 cm
Cause:

• Fetal renal defect (Not making urine)
• mainly from a blocked pathway
• could be underdev kidneys
• Membrane leakage (most important)
• Placental Insufficiency
• placenta has dec blood supply

Result:

• Fetal death
• Pulmonary hypoplasia
• Skeletal/facial defects (no zero g from fluid -> P)
• Amniotic Band Syndrome

Polyhydramnios (too much fluid)
Found if largest pocket of amniotic fluid is >10 cm
Cause:

• Reduced fetal swallowing
• Mat. diabetes mellitus, uremia
• Open neural tube
• stimulation of kidneys -> inc fluid (urine) prod

Result:

• Premature uterine contractions

HD124

Placenta Size and Structure

Function

Growth

• Increases in thickness and diameter until 16th week
• Increases in diameter alone after 16th week

At term

• Circular, spongy, 15-20 cm in diameter, 4cm thick
• 500 grams (about 1/6th weight of fetus)
• Blood flow reaches 1 litre/min

Has 15-20 cotyledons

• major branch structures of umbilical vessels (semi-organs)
• Many villi in each cotyledon (inc blood flow)

Umbilical Chord: 2 arteries, 1 vein

Modulates the maternal environment for normal fetal development

Placental insufficiency -> Intrauterine growth restriction and inc perinatal morbidity and mortality

HD124

What crosses/doesn't cross placenta?

Does:

From fetus

Waste Products (CO2, urea, uric acid, bilirubin)
RBC antigens, Hormones

From Mother:

Antibodies (IgG)

Viruses: Cytomegalovirus and Rubella

Doesn't:

Bacteria, heparin, transferrin, IgS and IgM

HD124

Multiple Pregnancies

Dizygote Twins (fraternal) – 66% twins

• two oocytes - two sperm
• separate amnion and chorion
• placentas may fuse if implantation sites are adjacent
• but still have separate blood supplies
• increases with maternal age, racial differences

Monozygote Twins (identical)

• Usually split at blastocyst stage
• Division inner cell mass

If they split...

Very early after fertilization (~30% of MZ)

• Each embryo has own chorion and amnion
• Placentas may fuse if implantations are close
• Non fused may look like DZ twins (Diamniotic, dichorionic, separate placentas)
• Fused blood supply can lead to twin transfusion syndrome (Diamniotic, dichorionic, fused
  placentas)

4-8 days post conception (~65% of MZ)

• One placenta, One chorionic sac, Two amniotic sacs
• Anastomosis of placental vessels and arteriovenous communication between circulatory systems of twins can lead to win transfusion syndrome

8-12 days post conception (~5% of MZ)

• Single placenta, chorion, amnion

Greater than 12th day post conception

• Conjoined Twins

Note: All monochorionic (only MZ) twins have placental vascular anastomoses (connections). Also look at diagrams in HD124 for clarification! Very testable.

HD0124

Twin–Twin Transfusion Syndrome

• Major complication of MC/MZ twins (20%)
• Untreated = high perinatal morbidity/mortality
• Recipient - Polyhydramnios and cardiac overload
• Donor - Oligohydramnios and anemia
• May result in either/both twin dying in utero
• Most severe cases are diagnosed early (<25 wks, >80 mortality)
• Interventions:
• Conservative – bed rest, inhibiting premature labour (>28wks)
• Amnioreduction (removal of fluid)
• Laser ablation of anastomoses
• Elective termination of pregnancy

HD013

Major and Minor Birth Defects (6 each)

Birth Defects: Epi & Etiology

Major - Requires intervention

1. Anal atresia
2. Esophageal atresia
3. Cleft lip/palate
4. Congenital heart disease
5. Meningomyelocele (NTD)
6. Limb deficiencies

Minor - No intervention required

1. Bifid uvula
2. Clinodactyly
3. Ear tags or pits
4. Epicathicfolds
5. Hemangioma
6. Syndactylly

One identifiable birth defect:

At birth: ~ 2-3%

At one year: ~ 5%

Multiple congenital anomalies (MCA): 7 per 1000
Minor anomalies: 10-15%

Hospital admissions: ~ 20%
Multiple congenital anomalies: 30-50% Post-neonatal deaths

Causes (Most->least common):

1. unknown
2. multifactorial (1+2 = 75%)
3. chromosomal
4. environment
5. monogenic

HD013

Errors in Morphogenesis Leading to
Birth Defects: 4 types

1. Malformation: A malformation is a morphologic defect of an organ/part of an organ/larger region of the body resulting from an intrinsically abnormal developmental process.

Ex. Neural Tube Defects (Folic acid dec risk from 3.5% -> 1.0%)

2. Deformation: An abnormal form, shape, or position of a part of the body caused by mechanical forces

Ex. squished face/lung hyperplasia from severe oligohydroamnious

3. Dysplasia: An abnormal organization of cells into tissue(s) and its morphologic result. It is the process (and the consequence) of dyhistiogenesis

Ex. Marfans -> Enlarged aortic root and occular problem?

4. Disruption: A morphologic defect of an organ, part of an organ, or a larger region of the body resulting from the extrinsic breakdown of, or an interference with, an originally normal developmental process

Ex. Amniotic band formation

Ex. Gastroschisis -> vascular disruption leading to GI extruding from abdomen

HD013

Patterns of Morphologic Defects in Birth Defects (3)

1. Sequence: A sequence is a pattern of multiple anomalies derived from a single known or presumed prior anomaly or mechanical factor

Ex. Robin Sequence: First the tongue is pushed backwards and as a result the palette doesn't drop down and you get a U shaped cleft -> leads to resp blockage from tongue

2 pathways:

Oligohydramnios (etiology) -> Extrinsic mandibular  deformation (Pathogenesis) -> Robin Sequence (Phenotype)

or...

Connective tissue disorder (etiology) -> Intrinsic mandibular hypoplasia Failure of connective tissue penetration across palate (Pathogenesis) -> Robin Sequence (Phenotype)

2. Syndrome: A pattern of multiple anomalies thought to be pathogenetically related and not known to represent a single sequence or a poloytopic field defect. Cause is known.

Ex. Smith-Lemli-Opitz Syndrome or Downs Syndrome

3. Association: A nonrandom occurrence in two or more individuals of multiple anomalies not known to be a polytopic field defect, sequence, or syndrome. Like syndrome, but cause is not known.

Ex. CHARGE Association

Coloboma (80%)

Heart defect (90%)

Atresiachoanae (60%)

Retarded growth (90%)

Genital anomaly (75%)

Ear anomaly (90%)

Ex. VATERL Association

V= Vertebral anomalies
A= Anal atresia
TE= TracheoEsophagealatresia/fistula
R= Renal anomalies or radial ray defects
L = Limb anomalies

HD049 - Assigned Reading

What influences and factors determine sexual
orientation and gender identity

A variety of neuroanatomical studies have been conducted, with some interesting findings.  In a nutshell, determining either of these is a combination of nature and nurture.  However, I’ll outline the studies for you a little:

• 1978 – Gorski working with rats -> finds an area of the brain in rats that is bigger in males than in females.
• 1982 – rats once again -> females exposed to androgens show mounting behavior, males who have their normal androgen exposure stopped show lordosis behavior (lordosis is “presenting”…)
• 1989 – Allen -> finds out that there is an area in the human brain that is bigger in males than in females
• 1991 – Levay -> that area in the human brain that is bigger in males than in females is also 2-3x bigger in heterosexual males than in homosexual males.
• A variety of neuropeptides are thought to be important in determining orientation; most notably oxytocin in females and AVP in males.
• In addition, familial studies have shown that in identical twins, if one twin was homosexual then the other was also homosexual 52% of the time (reared apart).  Thia number drops to 22% for fraternal twins, and 9% for non-twin siblings. 

As stated above, it is generally agreed that there is a combination of both genetics and environment influencing sexual orientation and gender identity.  It is important to note however, that they are not voluntary choices

HD071

Various Stats on Sexual Behaviour

# of sex partners in past 12 months

• 1 partner most common (♂: 67%, ♀: 75%)
• 5+ partners least common (♂: 5%, ♀: 2%)

# of sex partners since age 18 – distribution fairly spread out

• 5-10 partners most common in ♂ (23%), 2-4 partners second-most (21%)
• 2-4 partners most common in ♀ (36%), 1 partner second-most (31%)

majority of people are faithful to their spouses

• > 80% ♀, 65-85% ♂

Couples in specific age, race/ethnicity and/or at levels of education have sex with people from that similar group

• 63% of married couples introduced through social network (family, friends, etc.)
• Couples who eventually marry usually wait a while before sex

First sexual intercourse

• > 90% ♂ wanted it, 70% ♀ wanted it
• differences between men & women as to reasons for the first sex – 51 % of men out of curiosity; 48 % of women out of affection

Frequencies

• Survey answer equally distributed between “not at all/few times/YR”, “few times/month” and “2+ times/week” (~1/3 each, for men & women)
• Married & cohabiting couples are most likely to have sex

Duration

• 70% of men – 15’-1 hour
• 11% of men, 15% of women - < 15’

Orgasms

• 30 % of ♀ – consistent orgasm with 1˚ partner
  higher among married ♀ (than single)
• 75 % of ♂ – consistent orgasm with 1˚ partner

Types of sex

• Vaginal intercourse thought to be most appealing form of sex by majority of men & women. Most perceived vaginal intercourse to be a form of sex (vs. oral sex – 40 %)
• Oral sex 60 % of women, 80 % of men found it appealing (fairly commonly performed/received)
• Anal sex 5 % of women, 14 % of men found it appealing
• rarely performed – 26 % for men, 20 % for women

Men think about sex more often than women
Greater frequency of forced sex with women than men (22 % vs. 2 %)
Men masturbate more frequently than women

HD109

Masters and Johnson

Phsyiology: Men

Physiology: Women

Excitement -> Plateau -> Orgasm -> Resolution

Elderly Men:

Marked decline all phases
Prolonged plateau, less desire to orgasm
Weaker orgasm, rapid penile detumescence
Prolonged refractory period, up to days

Elderly Women:

Progression not automatic
Elongation of excitement and plateau phases
Orgasmic contractions decrease in number and intensity

• Testosterone levels gradually decline
• More time required to obtain / maintain an erection
• Reduction of semen volume
• Reduced sperm motility, typical forms
• Force and volume of ejaculation less, retrograde
• ejaculation

• Decreased vaginal lubrication
• Atrophy of the bladder
• Thinning of the vaginal mucosa
• Decreased estrogen levels
• Decreased vaginal length and width
• Loss of vulvar tissue
• Decrease in the size of the clitoris

Note: Both men and women lose testosterone levels with age

HD109

Drive, Desire and Activity

Biggest obstacle to sexual activity...

Do not equal each other

Drive

• Gradually decreases with age
• Likely physiologically based
• Drive is lower in females than males throughout the life span

Desire

• Complex interaction of many factors
• Drive
• Expectations/ values/ beliefs
• Motivation
• Body image
• Menopause: positive or negative
• Chronic Illness
• Medication FX

In elderly is a lack of a partner, esp women

HD109

Sex in the Elderly Stats

STIs in Elderly

• Americans >60
• 48% report that they were sexually active (sex at least once per month).
• 74% of the sexually active men and 70% of the sexually active women reported being as satisfied or even more satisfied with their sexual lives than they were in their 40's
• Sex with a partner in the previous year was
  reported by:
• 73 percent of people ages 57 to 64
• 53 percent of those ages 64 to 75
• 26 percent of people 75 to 85
• Most common in barrier in men was Erection difficulties
• Most common in barrier in women was Low Desire
• One out of seven men used Viagra or other substances to improve sex
• Only 22 percent of women and 38 percent of men had discussed sex with a doctor since age 50

• 11 percent of all new AIDS cases are in people over the age of 50
• New AIDS cases rising faster in the over 50 population than in people under 40.
• Heterosexual transmission in men over 50 is
  up 94 percent
• Heterosexual contact and needle sharing
  among IV drug users older than 50 are the
  main causes of HIV infection in seniors.